Angiosome-directed revascularisation and the woundosome paradigm in chronic limb-threatening ischaemia: a narrative review
Windy Cole, John Kirby, Steven Sauk, Walaya Methodius-Rayford, Marshall Medley, Amy Couch, Jacob Wielgomas, Raymond Abdo, Lauren McCarthyObjective:
Revascularisation is central to limb salvage in chronic limb-threatening ischaemia (CLTI) and diabetic foot ulceration (DFU); however, the optimal method for selecting target vessels remains uncertain. The angiosome model has traditionally guided revascularisation planning, while the emerging woundosome concept emphasises wound-level perfusion, collateral circulation, microvascular function, wound severity and multidisciplinary care. This review evaluated whether current evidence supports angiosome-guided revascularisation alone or a more wound-centred approach.
Method:
A structured review of PubMed/MEDLINE, Embase, Scopus and Cochrane Library databases was conducted from inception to May 2026. Eligible studies included guidelines, systematic reviews, meta-analyses, randomised trials and comparative cohort studies reporting wound healing, limb salvage, major amputation, amputation-free survival or mortality in adults with CLTI and/or DFU undergoing revascularisation.
Results:
Direct angiosome revascularisation was associated with improved wound healing and limb salvage compared with indirect revascularisation without collateral support. Across multiple evidence syntheses, direct revascularisation and indirect revascularisation with preserved collaterals achieved comparable outcomes and both outperformed indirect revascularisation without collaterals. Functional measures of perfusion, particularly wound blush, were stronger predictors of healing and limb salvage than angiosome alignment alone. Wound severity, assessed by Wound, Ischaemia, Foot Infection (WIfI) stage classification, independently predicted outcomes, whereas the significance of direct angiosome perfusion diminished after adjustment for wound characteristics. Contemporary guidelines emphasise maximising perfusion to the wound bed rather than strict anatomic angiosome targeting.
Conclusion:
The angiosome model remains an important anatomical framework but does not fully account for perfusion heterogeneity, collateral circulation and wound-specific factors. The woundosome concept may complement angiosome-guided planning by emphasising functional wound-level perfusion. Current evidence supports an integrated strategy that prioritises direct revascularisation when feasible while incorporating collateral assessment, wound blush, WIfI staging and multidisciplinary care. Prospective validation of the woundosome concept is warranted.